Healthcare Provider Details

I. General information

NPI: 1093904161
Provider Name (Legal Business Name): MARY ANN HULTGREN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 BOSTON POST RD
WEST HAVEN CT
06516-1918
US

IV. Provider business mailing address

121 LEDGEWOOD DR
NORTH BRANFORD CT
06471-1816
US

V. Phone/Fax

Practice location:
  • Phone: 203-624-5515
  • Fax:
Mailing address:
  • Phone: 203-481-8658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number006210
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: